The fourth in a series of five articles about maternal survival organised by the The Lancet Maternal Survival Series steering group.

Abstract:Coverage of cost-eff ective maternal health services remains poor due to insuffi cient supply and inadequate demand for these services among the poorest groups. Households pay too great a share of the costs of maternal health services, or do not seek care because they cannot aff ord the costs. Available evidence creates a strong case for removal of user fees and provision of universal coverage for pregnant women, particularly for delivery care. To be successful, governments must also replenish the income lost through the abolition of user fees. Where insurance schemes exist, maternal health care needs to be included in the benefi ts package, and careful design is needed to ensure uptake by the poorest people. Voucher schemes should be tested in low-income settings, and their costs and relative cost-effectiveness assessed. Further research is needed on methods to target financial assistance for transport and time costs. Current investment in maternal health is insufficient to meet the fifth Millennium Development Goal (MDG), and much greater resources are needed to scale up coverage of maternal health services and create demand. Existing global estimates are too crude to be of use for domestic planning, since resource requirements will vary